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PPD RECURRING DEBITS AUTHORIZATION
NAME:
CONTACT #
WITHDRAWAL START DATE: 8", 15°, oF 30" of the month}
WITHDRAWAL AMOUNT: $
‘TYPE OF TAXES AMOUNT TO REMOVED FOR:
(PLEASE SELECT ALL THAT APPLY)
Personal Property Account #.
Real Estate ‘Account #
Both
| (we) hereby authorize Russell County Treasurer’s Office hereinafter called the COMPANY, to initiate debt entries to my (our)
(PLEASE SELECT ONE)
Checking Savings Account
incicated below at the depositor financial institution named below, hereafter called DEPOSITORY, and to debit or credit the same to such account. If
this tem is returned unpaid, | authorize an additional returned chéck fee ofthe maximum account as allowed by the state ta be charged to this account.
Depository Name:
Routing Number: ‘Acoount Number:
‘Same amount to be debited each biling period.
(Or, | approve varying amounts between a range of $and $
‘Number of Payments, or Indafinitely (check here).
Frequency of Payments: (PLEASE SELECT ONE) __ Monthly Weekly
‘This authorization isto remain in fll force and effect for the number of payments authorized above or until the COMPANY and DEPOSITORY
reasonable opportunity to act on it
Name: De Date:
Signature:
Ploase attach a volded check to this authorization,